Download the Formal Workshop Application - (ADAMHS) Board of Cuyahoga

100
Formal Workshop
Application for
Presentation
Application Directions:
Complete the attached application in the spaces provided as directed below. If the application is for multiple-days or
concurrent sessions, we must have all the information requested below for EACH session.
1. WORKSHOP TITLE: Limit to 60 characters.
2. WORKSHOP DESCRIPTION: A paragraph describing the session and what you will cover.
Example:
To Speak or Not To Speak: How to do an effect presentation
Do you fear speaking in front of an audience? Would you rather have a tooth pulled then to stand in front of perfect strangers and talk? Does the very
thought of public speaking make your hands sweat, your throat go dry and your heart pound? If any or all of these describe you, then you’ll want to
attend this workshop. You’ll learn the secret that every public speaker knows about anxiety. You’ll learn what you need to do to improve on your public
speaking skills. And you’ll learn who should never get in front of an audience to speak.
3. WORKSHOP TARGETED LEVEL: (Open, Entry, Intermediate, Advanced)
Open Level includes community advocates, family members and concerned others. Entry level includes CDCA &
Registered Applicants for Prevention. Intermediate Level includes, LCDC II, LSW, LPN. Advanced Level includes PC, PCC,
LISW, LCDC III, LICDC, RN, Ph.D. and MD.
4. AGENDA: Provide a detailed description of what you will do during the time allotted. Please indicate time for all
segments, including breaks and meals.
Example:
9:00-10:30
10:30-10:45
10:45-12:00
Comparisons of co-morbid diagnosis
Treatment options that work
Break
Chemical Dependency
Eating Disorders
Self-Injurious Behaviors
Interactions between diagnoses
5. LEARNING OBJECTIVES: List 3-5 learning objectives. Format as what participants will be able to DO after
the session, not what the presenter intends to COVER during the session. Begin or use in the sentence each objective
with a verb from the attached list of behavioral verbs*.
6. PRESENTER INFORMATION: Name, mailing address (street, city, state, zip and country if outside US), day and
evening phone numbers, email. Also include degrees, professional license numbers, expiration dates, and states where
they are valid. End with current job description (one sentence) & a short bio for marketing purposes.
Example:
John Smith
Licensed Psychologist, #043-005630, GA - Expires 10-31-03
1443 Euclid St SW
Starke, FL 32237
909-123-4567 (d)
909-987-6543 (e)
email: [email protected]
Job Description: Associate Professor, ABC University, Psychology Department
Bio: John Smith, Ph.D. is a licensed psychologist with a current clinical practice focus in adult services. His practice includes conducting assessments,
testing and evaluation, creating treatment plans and conducting individual and group psychotherapy for individuals with emotional and behavioral
problems, including chemical dependency disorders.
7. RESUMES / CURRICULUM VITAS:
Attach a current resume, to include: education, training, degrees, major area(s) of study, institution(s) from
which degree(s) were received, and year(s) received; publications, presentations, and any pertinent experience
that qualifies the presenter on the topic to be presented.
8. EQUIPMENT REQUIRED: Select the equipment you need to conduct your workshop.
9. HANDOUTS: Copies of each handout you plan to distribute during your workshop.
10. BIBLIOGRAPHY (references or other valid sources of information)
Provide a minimum of 5 resources used to research the topic and/or for further reading by the attendee. Please do not
include more than one source authored by the presenter. Please submit in correct bibliographic format.
VERB LIST FOR WRITING OPERATIONAL/BEHAVIORAL OBJECTIVES*
KNOWLEDGE
COMPREHENSIVE
APPLICATION
ANALYSIS
SYNTHESIS
EVALUATION
Cite
Associate
Apply
Analyze
Arrange
Appraise
Count
Classify
Calculate
Appraise
Assemble
Assess
Define
Compare
Complete
Contract
Collect
Choose
Discover
Compute
Demonstrate
Criticize
Compose
Critique
Draw
Contrast
Dramatize
Debate
Construct
Determine
Identify
Describe
Employ
Detect
Create
Estimate
Indicate
Differentiate
Examine
Diagram
Design
Evaluate
List
Discuss
Illustrate
Differentiate
Detect
Grade
Name
Distinguish
Interpret
Distinguish
Formulate
Judge
Point
Estimate
Interpolate
Experiment
Generalize
Measure
Quote
Explain
Locate
Infer
Integrate
Rank
Read
Explore
Operate
Inspect
Manage
Rate
Recite
Express
Order
Inventory
Organize
Recommend
Recognize
Extrapolate
Predict
Question
Plan
Revise
Record
Interpret
Practice
Separate
Prepare
Score
Relate
Interpolate
Relate
Summarize
Prescribe
Select
Repeat
Locate
Report
Produce
Test
Select
Predict
Restate
Propose
State
Report
Review
Specify
Tabulate
Restate
Schedule
Synthesize
Tell
Review
Sketch
Trace
Translate
Solve
Write
Translate
Use
Utilize
Behavioral Terms that are NOT measurable and do NOT meet ADAMHSCC criteria for approval.
Appreciate
Be aware of
Be able to know
Be familiar with
l
Communicate
Enjoy
Grasp the significance of
Have an understanding of
l
Increase
Know how to
Learn how to
Motivate
d
d
Applicant m ust state objectives in operational/ behavioral term s.
Training Institute Workshop Application
1. Workshop Title: (limit 60 characters)
2. Workshop Description: (limit 700 characters)
3. Workshop Targeted Level: (check one)
Open
Entry
Intermediate
Advanced
4. Agenda: (limit 400 characters)
AM Agenda
5. Learning Objectives: (limit 700 characters)
PM Agenda
6. Presenter Information:
Name:
Address:
City:
State:
Phone:
E-mail:
Zip:
Qualifications/Degrees/License Number/Etc.:
Job Title/Description:
Short Biography:
7: Resumes/Curriculum Vitas: Attach a Word or PDF document
8. Equipment Required: (check all that apply)
No equipment needed
Computer
LCD Projector/Monitor
Overhead Projector
Slide Projector
CD/Cassette player
VCR/DVD
Internet access
Flip Chart
Microphone
Other:
9. Handouts: Attach a Word or PDF document for each of your handouts.
10. Bibliography (references or other valid sources of information):(limit 1,000 characters)
Print
Mail to:
Scott Osiecki
Director of External Affairs
ADAMHS Board of Cuyahoga County
2012 West 26th St., 6th Fl.
Cleveland, OH 44113
Submit
Be sure to attach your resume and/or
handouts to your e-mail.